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Book Review   |    
Sally L. Satel
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.2.276
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edited by Yuval Neria, Raz Gross, Randall Marshall, and Ezra Susser; New York, Cambridge University Press, 2006, 674 pages, $110

Dr. Satel is affiliated with the American Enterprise Institute, Washington, D.C.

Within weeks of the September 11th terrorist attack on the World Trade Center many psychiatrists predicted that New Yorkers would experience posttraumatic stress disorder (PTSD) in epidemic proportions. Well over $100 million in taxpayer and private dollars poured into the city to establish vast treatment networks. In the end, however, the psychic doom forecasted was never documented, and the value of training thousands of mental health workers remains questionable.

Nowhere is this better illustrated than in 9/11 a 35-chapter book edited by four Columbia University researchers.

As three early chapters in the book reveal, we still do not know how many people were clinically affected by September 11th. Epidemiological research methods employed by researchers were not rigorous enough to nail down DSM diagnoses. For example, assessment techniques could not distinguish short-lived, predictable distress—such as sleeplessness, hypervigilance, and difficulty concentrating—from actual clinical pathology. Two of the research teams contributing chapters to this book did not assess functional impairment, which is vital to distinguishing symptoms from disorders; a third team did try to measure disability but used a screening tool for diagnosis.

Well aware of these limitations, the authors of the first three chapters used the term "probable" to qualify diagnoses of PTSD. One could even argue that the term "possible PTSD" would have been more accurate, particularly in light of the swiftness with which post-9/11 symptoms dissipated. According to researchers from the New York Academy of Medicine, the rate of probable PTSD among Manhattan residents after the attacks was 7.7%. Six months later, it had declined by 90%, an unprecedented speed of recovery. By contrast, the 1995 National Comorbidity Survey found only a 15% decrement of PTSD in the general population within six months of onset. Such a marked discrepancy—90% versus 15%—should make one wonder about the true nature of the phenomenon diagnosed as "probable" PTSD.

The chapters on counseling interventions mounted in New York City after the terrorist attacks also miss a solid bottom line. Although planners will welcome the accounts of logistics, public education campaigns, and utilization described in those chapters, the lack of a comparison group makes it impossible to judge effectiveness, and cost-effectiveness, of these efforts and, therefore, to draw public health lessons from them. Finally, the absence of a discrete chapter on inpatient and clinic-based treatment utilization is notable. Though the published literature on this is modest, it describes a negligible up tick in treatment use and medication prescribing in the wake of September 11th.

9/11 contains strong review chapters, including summaries of methodological controversies in disaster research, treatment efficacy, and disaster response. Chapters on journalists and September 11th and on leadership by people like Mayor Rudolph Giuliani and Red Cross president Bernadine Healy are novel contributions. For this reader, the best part of the volume is the last section called "Perspectives on Response and Preparedness." Three bold chapters therein question the orthodoxies of traumatology.

The first is called "The Epidemiology of 9/11: Technological Advances and Conceptual Conundrums" by psychiatric epidemiologist Naomi Breslau and clinical psychologist Richard McNally, who ask a number of pressing questions that trauma experts need to confront squarely. For example, what exactly does it mean to be "exposed to 9/11," a phrase used throughout the book? Could PTSD caused by narrowly escaping the World Trade Center attacks possibly be the same clinical phenomenon as PTSD from watching the events on television? It strains logic to think so, but according to DSM-IV, with its expanded definition of stressor, the answer is yes. Breslau and McNally call this "bracket creep" and note its worrisome implications for diagnosis and treatment—not to mention forensic practice and the increasing societal penchant for medicalizing otherwise normal, albeit painful, responses to loss and threat.

British psychiatrist and epidemiologist Simon Wessely contributes the second chapter, called "What Mental Health Professionals Should and Should Not Do." His prescription is this: restrain themselves. The best psychological support, he says, actually flows from practical help such as provision of food, water, means of communication with family and friends, transportation, financial help, and so on. "I continue to have some skepticism about the immediate role of the mental health professional in the acute drama, other than his or her role as a good citizen," Wessely concludes. "Once the dust has settled, literally and figuratively, those with defined psychiatric disorders can now access decent quality treatment."

Arieh Shalev, an Israeli psychiatrist, speculates on the uniqueness of the attack in the third chapter, "Lessons Learned From 9/11: The Boundaries of a Mental Health Approach to Mass Casualty Events." He wonders "whether PTSD symptoms are, indeed, the essential measure of a maladaptive response to mass trauma." He later notes the unusually intense focus on psychological aspects of the disaster's impact. As Shalev puts it, the fact that most of the city remained infrastructurally intact "may again have contributed to the salience of psychological reactions, which, in other disasters can become second in importance to other needs, such as food and shelter needs."

As is common with edited books, 9/11 is redundant in parts and contains internal contradictions. Depending on the chapter, for example, one can read about a populace that weathered calamity quite well or a city that suffered mental crisis. Some chapters extol the great need for mental health professionals in the immediate aftermath of disaster, whereas others question whether acute deployment of mental health professionals is even necessary and caution against the self-fulfilling prophecy of morbid predictions.

These conflicting perspectives are barely engaged by psychiatrist Randall Marshall, one of the book's editors and author of the concluding chapter. He does, however, take a most ungentlemanly swipe at contributors Breslau and McNally—who claim that an epidemic of PTSD never materialized—in likening them to the "conspiracy theorists who believed the moon landings had been elaborately staged." I, too, have questioned the existence of an epidemic. Marshall goes on to accuse them, unjustly, of "outright denial of human suffering" and of "abandon[ing] the basic principle that mental health scientists … should respond to public health needs." Then, with near-comic timing, he laments that the "the post-9/11 debate has become so shrill."

This book is a good reference for those interested in the aftermath of September 11th. If anything, it tells us more about the mental health profession's response to the terrorist attacks on the World Trade Center and the Pentagon than about civilians' responses. Indeed, as a reader I felt as though I were left hanging. After all, we still do not know how many individuals were clinically afflicted by September 11th or whether counseling programs established to help New Yorkers had a meaningful public health impact and justified spending millions to create them.

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